Comparison of psychopathology, purpose in life and moral courage between nursing home and hospital healthcare workers during the COVID-19 pandemic

The COVID-19 pandemic deeply affected healthcare workers, although the impact may have differed according to different workplace contexts. The aim of this current research was to compare the psychopathology presented by hospital versus nursing home healthcare workers during the COVID-19 pandemic and to analyse the predictive role of purpose in life and moral courage in the appearance of psychopathology. This was an observational, cross-sectional study carried out on a sample of 108 healthcare workers, 54 each from a hospital or nursing homes, who were recruited during the 5 and 6th waves of the COVID-19 pandemic in Spain. Various self-reported scales were used to assess anxiety, depression, acute/post-traumatic stress disorder, drug and alcohol abuse, burnout, purpose in life, and moral courage. Compared to the hospital healthcare workers, nursing home healthcare workers had higher scores and a higher prevalence of anxiety (74.1% vs. 42%), depression (40.7% vs. 14.8%), and post-traumatic stress disorder (55.6% vs. 25.9). In the overall sample, purpose in life was a protective factor against psychopathology (OR = 0.54) and burnout (OR = 0.48); moral courage was a protective factor against depression (OR = 0.47) and acute stress (OR = 0.45); and exposure of family/friends to SARS-CoV-2 was a risk factor for acute stress (OR = 2.24), post-traumatic stress disorder (OR = 1.33), and higher burnout depersonalisation subscale scores (OR = 1.84). In conclusion, the increased presence of psychopathology in nursing home healthcare workers may be influenced by workplace and occupational contexts, personal factors such as exposure of family/friends to SARS-CoV-2, or internal dimensions such as purpose in life and moral courage. This knowledge could be useful for understanding how a future epidemic or pandemic might affect the mental health of healthcare workers in different labour contexts.


Purpose
The objective of this current study was to compare the presence of psychopathology and burnout in hospital and nursing home HCWs during the COVID-19 pandemic and to analyse the possible effects of PIL and MC in this context.We hypothesised that: (1) psychopathology and burnout would be higher in nursing home healthcare workers than in hospital healthcare workers; (2) purpose in life would be a protective factor and moral courage a risk factor for psychopathology and burnout both in nursing home and hospital healthcare workers.
Thus, this study aimed to improve our understanding of the mental health of HCWs in nursing homes during the COVID-19 pandemic, which has been under-researched in most studies.Furthermore, we hoped that analysing PIL and MC in special contexts such as a pandemic would deepen our understanding of the nature and effect of these factors.

Study design
Given the research objective and exploratory nature of this work, we conducted a cross-sectional study following the STROBE guidelines for observational studies.Therefore, we limited the inclusion and exclusion criteria so that all participating HCWs had worked during the COVID-19 pandemic and spoke Spanish.G*Power software (v3.1.9.4) was used to estimate the required sample size, considering an expected effect size of d = 0.55, an alpha of 5%, and beta of 20% for 2 groups, with an allocation ratio of 1.Hence, we estimated that an overall sample size of 84 or 88 would be required to perform sufficiently powered Student t or Mann-Whitney U tests, respectively.

Instruments and data collection
The questionnaires were provided to the HCWs from the Consorcio Hospitalario Provincial de Castellón both in paper and electronic formats between September and November 2021, and because of their multicentric nature, to nursing home HCWs only in an electronic format between October 2021 and January 2022.No differences were expected because the same surveys were sent in both cases.To avoid duplication or fraud with the online surveys, the first and last names of the participants and their work e-mails were collected and the surveyees were assigned an anonymous identification code.This information was encrypted in a separate database which only the principal investigator had access to.
Participants were required to sign their informed consent to participation before commencing the study.All the surveys were self-administered and had been previously validated for Spanish speakers.The questionnaires and methodology were similar to those used in previous studies 8,18,21 .
First, the participants completed a sociodemographic questionnaire that asked about their age, sex, religiosity, marital status, professional category, level of responsibility/role, contract type, time working in their current role, history of physical conditions or mental health disorders, COVID-19 vaccination status, and whether they smoked and the number of cigarettes they smoked.
Second, personal and family/friend exposure to SARS-CoV-2 was assessed using a questionnaire that had been previously employed during the COVID-19 pandemic 18 .PIL was evaluated using the Purpose in Life Test, a 20-item Likert scale test that scores, from 20 to 140, the extent to which each individual considers that their life has a purpose (reliability = 0.89; adequate factorial validity) 16 .This test comprises four dimensions (perception of meaning, experience of meaning, goals and tasks, destiny-freedom dialectic) and has a cut-off point (CP) score of 113, with those exceeding this considered to have a PIL.MC was analysed using the Moral Courage Scale for Physicians (MCSP), a 9-item dichotomous scale that scores, from 0 to 9, the ability of medical personnel or healthcare professionals to face disapproval when doing what they believe is their duty (reliability = 0.74; adequate factorial validity) 22 .The MCSP does not have a CP and higher scores indicate greater MC.The Professional Moral Courage Scale (PMCS), which comprises 12 dichotomous items with a maximum score of 12 (reliability = 0.81; adequate factorial validity) 23 , was also used to analyse MC.
Third, psychopathology and burnout were assessed using various measures described below.Total scores and dichotomous variables were calculated for these scales, and the participants were divided into those who scored above the CP of each scale, thus screening positive for the psychopathology, and those who did not.Anxiety was measured using the Beck Anxiety Inventory (BAI), a 21-item Likert scale with scores ranging from 0 to 63 and a CP of 8 (reliability = 0.90; adequate factorial, discriminant and criterion validity) 24 .Depression was assessed using the Beck Depression Inventory (BDI-II), also a 21-item Likert scale with a CP of 14 (reliability = 0.89; adequate factorial, convergent, discriminant, and criterion validity) 25 .Acute stress disorder was assessed using the Acute/Post-Traumatic Stress Disorder Scale (ETEA-PT), a 15-item Likert scale based on the DSM-5 criteria for these disorders with a CP of 9.An additional ETEA-PT item that asked whether symptoms had lasted more than one month was used to assess PTSD (reliability = 0.81) 18 .Drug abuse was tested employing the Drug Abuse Screening Test-10 (DAST-10), a 10-item dicotomic scale ranging from 0 to 10 with a CP of 1 (reliability = 0.89; proven predictive validity) 26 .Finally, alcohol abuse and problems related to alcohol use were assessed with the Alcohol Use Disorders Identification Test (AUDIT), a 10-item Likert scale ranging from 0 to 40 with a CP of 6 for women and 8 for men (reliability = 0.75; adequate criterion and predictive validity) 27 .The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to evaluate the presence of burnout and its subdimensions.This Likert scale consists of 22 items and comprises three dimensions: personal accomplishment, emotional exhaustion, and depersonalisation (reliability = 0.71, 0.85, and 0.58, respectively) 28 .The score of each subscale is calculated by summing its items and, because of the dimensional complexity of burnout, both the overall score and the scores of one or several subdimensions have been used in the academic literature.Thus, in this current work, the presence of burnout was defined as a high level of either emotional exhaustion (CP ≥ 27) or depersonalisation (CP ≥ 10) 29 .
In addition, a three-item Likert scale was administered to ask participants about their subjective opinion of the change in their mental health since the beginning of the COVID-19 pandemic.Finally, an overall psychopathology score was calculated by summing the absolute scores of each of the psychopathology scales (BAI + BDI + ETEA/TP + DAST-10 + AUDIT).www.nature.com/scientificreports/

Data analysis
First, an exploratory (normality, independence, homoscedasticity, linearity, and non-collinearity) and descriptive study was undertaken.Second, to test hypothesis 1, sociodemographic characteristics, SARS-CoV-2 exposure, PIL, MC, psychopathology, and burnout were compared between the two study groups.Quantitative variables were evaluated using Student t and Mann-Whitney U tests (when the assumptions for the application of parametric tests were or were not met, respectively).Categorical variables were compared using Pearson chi-squared test.Third, to test hypothesis 2, generalized linear models and logistic regressions were created for the dependent variables, introducing personal or family/friend exposure to SARS-CoV-2, PIL, and PMCS as predictors.MCSP was excluded from the regression analyses because of collinearity problems with PMCS.Finally, the data were modeled using the PROCESS plugin (v3.4) for SPSS 30 to study the relationships between the most prominent variables in the regression models.Missing data were eliminated pairwise in each test or analysis.

Ethical considerations
The ethical principles set out in the Declaration of Helsinki and by the Council of Europe Convention were followed and the informed consent of all participants was obtained.Moreover, data confidentiality was guaranteed according to the General Data Protection Regulation (GDPR; 2018

Personal and family/friend exposure to SARS-CoV-2, purpose in life, and moral courage
Table 2 shows that there was significantly greater personal and family/friend exposure to SARS-CoV-2 in the nursing home group (Me = 4; interquartile range [IQR] = 3) than in the hospital group (Me = 2; IQR = 3.25) (Mann-Whitney U = 1,831.5,p = 0.02).Likewise, the MCSP scale score was significantly higher in the nursing home group (Me = 9; IQR = 1) than in the hospital group (Me = 8; IQR = 2) (Mann-Whitney U = 1,667.5,p = 0.009).Surprisingly, there were no differences in PIL between the two groups.

Generalized linear models, logistic regressions, and psychopathology data model
There were no differences in the predictors of psychopathology when nursing home and hospital HCWs were analysed separately, except in the case of personal and family/friend exposure to SARS-CoV-2, which could predict ETEA-TP in nursing home HCWs (β = 1.94; 95% CI [1.01, 3.73]; p = 0.04) but not in hospital HCWs.Table 4 shows the generalized linear models and logistic regressions used to predict the appearance of a psychopathology or burnout in the overall study sample.

Discussion
To the best of our knowledge, this is the first study to compare the appearance of psychopathology and burnout during the COVID-19 pandemic in nursing home and hospital HCWs, in addition to the predictive role of PIL and MC.Consistent with our first hypothesis, the prevalence of psychopathology was higher in nursing home HCWs than in hospital HCWs, as also previously reported in another Spanish study 15 .Furthermore, nursing home staff were more likely to have reported a deterioration in their mental health since the start of the pandemic.In this sense, professional category may have been one of the main reasons for these differences in psychopathology, because the nursing home cohort had included a higher percentage of nursing assistants.In fact, some studies have suggested that nursing assistants were one of the groups most affected by the COVID-19 pandemic 7,15 .Another reason may have been the high mortality rate (up to 50% of the deaths in the first wave) registered in Spanish nursing homes as a result of COVID-19 15 .
Although our hypothesis of a higher prevalence of burnout among nursing home HCWs was not supported, we demonstrated that burnout and psychopathology were closely related (Fig. 1).In fact, previous studies have shown that burnout can increase the prevalence of psychopathology 31 and vice versa 12 .However, some extrinsic factors such as personal and family/friend exposure to SARS-CoV-2 may have also played an important role in the appearance of psychopathology and burnout during the COVID-19 pandemic.In fact, this latter risk factor could predict acute stress and PTSD, as well as higher scores on the burnout depersonalisation subscale.Regarding this finding, a previous qualitative study indicated that nursing home HCWs said that one of their main concerns was the transmission of SARS-CoV-2 to their family and friends and that this worry was more stressful www.nature.com/scientificreports/ to them than contracting the virus themselves 32 .This fear may have led HCWs to feel trepidation when managing residents with COVID-19, which in turn, has been linked to a higher prevalence of PTSD and increased burnout depersonalisation subscale scores 33 , perhaps in response to a dissociative defense mechanism.
In addition to the extrinsic factors mentioned above, intrinsic dimensions such as PIL predicted both the occurrence of psychopathology and burnout, although MC only predicted psychopathology, thereby partially satisfying our second hypothesis.In line with both our second hypothesis and the results of previous studies 8, 18 , we observed that high levels of PIL were associated with lower scores for anxiety, depression, acute stress, PTSD, and burnout.These findings could be explained by the fact that PIL is framed within logotherapy and the salutogenic approach to wellbeing 34 .Thus, a high PIL would endow people with greater resilience and coherence in stressful situations, while the opposite situation would be related to a greater likelihood of developing mental health disorders 18,35 .Indeed, a study in nursing home staff during the COVID-19 pandemic showed that low resilience was associated with higher levels of depression 36 .
In contrast to our hypothesis, MC predicted lower depression and acute stress scores in our cohort.Although MC has often been identified as a risk factor for psychopathology because of its association with the concept of 'moral distress' , it may also be a protective factor against suffering moral distress and, in turn, psychopathology.This 'double-edged sword' effect depends on the ability of individuals to act in accordance with their moral expectations 37 , with a failure in being able to do so leading to psychopathology.This phenomenon is also related to the concept of 'moral resilience' , which refers to the ability to maintain or restore one's integrity in response to moral adversity.Indeed, moral resilience has been shown to moderate the relationship between exposure to potentially morally distressing events and moral distress and was correlated with lower anxiety and depression in HCWs during the COVID-19 pandemic 38 .Considering all the above, different authors have proposed several measures to improve crisis management in nursing homes, including the development of personalised action protocols for each site or coordination teams in conjunction with local healthcare services 39 .These measures could reduce the number of deaths among older adults and therefore, reduce the overwhelming work-related situations faced by HCWs that could affect their mental health 40 .The simultaneous development of resources focused on the mental health of HCWs, such as psychological support teams, peer-to-peer programmes, or coping groups, is also recommended.These measures would be useful in the prevention and management of the psychopathology developed during health emergencies 20,41 .In this regard, future management policies should include the systematic and regular assessment of signs of mental disorders in HCWs 9,40 .
Finally, several limitations to this work should be highlighted.First, this was a cross-sectional study, meaning that no inferences regarding causality can be made.Second, since a convenience and snowball sampling strategy were used, the number of people requested to participate in this study and their response rate could not be quantified.Therefore, potential non-response bias or early versus late bias could not be analysed.Furthermore, because of the urgency of the situation caused by the COVID-19 pandemic, measures to mitigate potential common methodological biases could not be implemented.Third, although the hospital sample was drawn exclusively from Castellón, the nursing home sample was recruited from different regions of Spain, leading to a small time lag between the collection of data from the two sample cohorts.Nevertheless, the incidence of COVID-19 in Spain remained broadly the same during both periods and was unlikely to have affected the outcomes.Fourth, although we wanted to address the impact of the pandemic in a naturalistic way by including non-clinical staff, since they may have had less contact with COVID-19, they could be considered non-frontline workers and thus influence the results.Nonetheless, a post hoc analysis to assess the relationship between SARS-CoV-2 exposure and professional categories found no differences between them.Finally, the main study limitation was the differences in sociodemographic characteristics between the two groups, which calls into question the comparability of the groups and role these differences may have played as a significant factor contributing to the results.However, this was an exploratory study with a small sample size compared to the large number of variables studied, thereby leading us to conduct parsimonious analyses.Notwithstanding, it would be interesting to control for these sociodemographic variables in future work in order to discriminate their possible role as confounding variables in the development of psychopathology.Nevertheless, it is still worth highlighting that the variables predicting psychopathology and burnout were almost the same in both groups.
Taken together, these limitations compromise the ability of this work to elucidate the full extent of the influence of PIL and MC on psychopathology or to recommend psychological approaches including these dimensions.Thus, future studies should consider this exploratory work and its limitations when trying to determine the usefulness of PIL and MC as targets of psychological treatments designed to prevent psychopathology.

Conclusions
The greater presence of psychopathology (anxiety, depression, and post-traumatic stress disorder) in nursing home healthcare workers during the 5 to 6th waves of the COVID-19 pandemic in Spain raises the question of its multifactorial nature and biopsychosocial factors involved in its development.
Regarding extrinsic factors, workplace environment played a central role in the lives of healthcare workers during the pandemic and factors such as professional category may have been of great relevance in the development of mental disorders.Regarding the personal sphere, personal and family/friend exposure to SARS-CoV-2 also played an important role in the appearance of psychopathology.In turn, intrinsic factors including purpose in life or moral courage buffered the effects of nosological elements mentioned above.

Table 2 .
Personal Total n =